Answer: the stubborn refusal of public hospitals to provide them to people who can’t afford them privately – that is, most people.
I love public hospitals. Some of my best healthcare experiences have come in public hospitals.
But sometimes public hospitals forget who and what they’re there for.
Colour me weird, but I always believed that public hospitals were there to provide the best possible care to those who need it, regardless of colour, creed or credentials of any other sort, including, most importantly, bank balance.
If people want to pay for private health insurance so they can pick their favourite surgeon, have a private room or schedule their induction to match their favourite grandmother’s birthday, bless ’em. You pays your money, you takes your choice. Excellent.
But public hospitals should provide the same care options for those who cannot afford the private route. Tell me I’m wrong.
Let’s talk about obesity
According to the WHO, obesity has tripled since 1975. Most of the world’s population live in countries where overweight and obesity kills more people than underweight. Thirty-nine million children under the age of five were overweight or obese in 2020.
In Australia, according to the recently released World Obesity Atlas 2023 report, 47% of adults will be obese by 2035, an annual increase of 2.2% between 2020 and 2035. Childhood obesity will increase at 2.6% per year. The impact on the national GDP of overweight will come in at 2.5%.
There are many touted “solutions” to obesity – prevention, of course, being the obvious one (but that’s a whole other rant). There’s semaglutide and the other incretin drugs – if you can get them. There is also bariatric surgery. Does it work over the long term?
(Before I attempt to answer that question, a confession of vested interest. I had a Roux-en-Y gastric bypass – through the private system – 15 months ago. I’ve lost 63kg, am no longer diabetic, halved my blood pressure medication, and postponed knee replacement surgery, probably by about a decade. I might say, despite having 30 years’ worth of private health insurance premiums behind me, I still had to harvest my superannuation fund for $10,000 to get it done. But again – that’s a whole other rant.)
Associate Professor Ahmad Aly and colleagues, writing in the Medical Journal of Australia in August 2022, said:
“Bariatric surgery, however, remains the most durable and effective treatment for obesity, achieving in most patients 20-30% TBWL for up to 20 years after surgery and improving comorbidities and quality of life. Randomised trials have demonstrated bariatric surgery to be superior in the treatment and control of type 2 diabetes compared with medical management, and improvements in sleep apnoea, metabolic syndrome, polycystic ovary syndrome, non-alcoholic steatohepatitis and arthritic disease have been extensively documented. Most compellingly, matched cohort studies have demonstrated clear reduction in all-cause mortality for patients with obesity undergoing bariatric surgery, with particular reduction in cardiovascular and cancer death compared with their non?operated cohorts. These health benefits translate to substantial health care cost savings, the magnitude of which is equivalent to smoking cessation.”
So, bariatric surgery seems like an obvious obesity-mitigation strategy that should be available to all Australians, regardless of their ability to pay. Right?
Sadly not. According to a Medical Services Advisory Committee public summary document, about 90% of bariatric surgery is done in the private health system.
When I interviewed Professor Aly in August 2022, he told me that stigma and, frankly, ignorance played their parts:
“The majority of [public] hospitals are still vested with this idea that obesity is a lifestyle issue, that bariatric surgery is not necessary treatment,” said Professor Aly. “It reflects an underlying lack of understanding of the biology, and reflects a lack of understanding of obesity as a disease. And it reflects a level of obesity stigma that persists.”
There is also a lack of willingness to invest.
“There is no funding for the establishment of a multidisciplinary clinic, which is absolutely crucial for helping to treat a person with obesity, otherwise, there’s no point doing the operation,” said Professor Aly. “We’re already spending that money … in our patients, treating them over and over and over again. We need to change our funding model to be able to redirect that in the appropriate way.”
There is also a fear of being swamped by the hordes of great unwashed obese poor who will come looking for bariatric surgery if it is made available widely in public hospitals.
That’s one of the reasons why the criteria for eligibility for public bariatric surgery is so narrow. For example, one of the few that offers it is the Alfred Hospital in Melbourne. They require candidates for surgery to have “either a BMI greater than 40, or less than 35 with two or more morbid obesity-related comorbidities; be aged between 18 and 65 years; and have tried but failed to achieve or maintain clinically beneficial weight loss using non-surgical measures”.
“If you just tried to operate on everybody, you’d be operating all day, every day, and you wouldn’t get through it because the burden is incredibly high,” said Professor Aly.
That says it all right there.
And here is where the Venn diagram between bariatric surgery and abortion merge.
Let’s talk about abortion
My colleague Holly Payne wrote back in January that “as of 2019, it was estimated that just 10% of abortion services were delivered in public hospitals across the country, despite the procedure being legal in most states and territories at that time”.
“Even when public hospitals do offer terminations, recent research published in the Australian Journal of Primary Health found that most referral pathways were unclear at best, and actively discouraged public referrals at worst.”
In NSW, according to Nine newspapers’ Kate Aubusson, “only 0.7% [of surgical abortions] were performed in public hospitals in 2020 after decriminalisation, the most recent available data from NSW Health shows”.
Why?
According to Dr Nicole Higgins, president of the RACGP, the religious beliefs of hospital directors – even those not affiliated with church organisations – are a factor in restricting access to abortion in public hospitals.
Speaking to the Community Affairs References Committee’s inquiry into universal access to reproductive healthcare on 28 February, Dr Higgins said:
“It is not just the religious based hospitals; it may also be state-based facilities if their director has a particular theological choice, which has certainly been the case in a lot of rural areas. This has been brought up particularly at Wagga. I know that in Mackay and Rockhampton in Queensland it’s been an issue. It is really important that access for women has to be, not just irrespective of postcode, but irrespective of the ethical or religious beliefs of the people or the organisations who are supporting the services … an example would be if you’ve had a failed medical termination of pregnancy, which requires surgical intervention. Some of these women are unable to access the private hospital, which may be Catholic, or the local state hospital, because of the beliefs of particular people involved, and they then have to travel long distances. It’s important that we actually have to separate religious and ethical beliefs from the delivery of care.”
Apart from public hospitals, I’m also inordinately fond of the separation of church and state, particularly when the state is represented by a public hospital paid for by my own ever-loving atheist tax dollars, thank you very much.
People with uteruses – yes, I am THAT woke; come at me, people – require abortions for many reasons. Sometimes those reasons are medical, sometimes they are about only having the means to feed the kids you already have.
The poorest need it most
It’s no surprise that it is the socioeconomically challenged populations of Australia who use public hospitals the most. That’s the point, after all.
It’s also not a surprise that obesity and overweight is most prevalent in low socioeconomic areas. As long as a pumpkin costs $10.50 and a Quarter Pounder with Cheese costs $7.40, that’s never going to change.
It’s not easy to figure out trends in abortion because national data is patchy at best, but it doesn’t take an RCT to know that poverty and postcode make it harder to access terminations.
All we need is for the state governments who control public hospitals to grow a spine and mandate that every publicly funded hospital must provide equitable access to both bariatric surgery and surgical abortions. Anything less negates everything public healthcare is supposed to be about.
Of course, state governments might not even realise there is a problem – nothing would surprise me. So perhaps hospital directors should take matters into their own hands, provide services of their own free will, and maybe, get swamped. They could then present the data to the government as evidence of need.
After all, you can’t fix a problem you don’t know exists.
Simples. Right?
